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Chapter 25 : Chronic Aspergillosis
Category: Clinical Microbiology; Fungi and Fungal Pathogenesis
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Chronic pulmonary aspergillosis was first described in humans, by Alexander Bennett in 1848, and numerous descriptive and diagnostic monikers have been used, including pulmonary aspergillosis with cavitation, symptomatic pulmonary aspergilloma, complex aspergilloma, and chronic granulomatous aspergillosis. The term chronic cavitary pulmonary aspergillosis describes patients in whom there is formation and expansion of multiple cavities over time. There are three discrete clinical entities subsumed under the term chronic Aspergillus rhinosinusitis, namely, chronic invasive Aspergillus rhinosinusitis, fungus ball of the sinus, and chronic granulomatous Aspergillus rhinosinusitis or paranasal Aspergillus granuloma. Various cutaneous manifestations are caused by Aspergillus spp., including onychomycosis, external otitis, and primary cutaneous aspergillosis. A pulmonary aspergilloma and fungus ball of the sinus are rounded conglomerates of hyphae, mucus, and cellular debris. The author has seen a few cases of Aspergillus bronchitis in the context of other chronic respiratory disease, but little has been written about it in the literature. Many different species of Aspergillus have been reported to cause onychomycosis, including A. fumigatus, A. versicolor, A. niger, A. terreus, and some rare species. This chapter talks about antifungal and surgical treatment and management of complications. Itraconazole and voriconazole are the preferred oral agents for chronic cavitary pulmonary aspergillosis (CCPA), with posaconazole being substituted for failure, toxicity, or emergence of resistance. Much-improved surgical and medical results are now reported, with long periods of remission on azole therapy or after surgical resection. The prognosis of a fungal ball of the maxillary sinus is also excellent, with a very low recurrence rate.
(A) Chest radiograph showing extensive cavitary disease occupying most of the left upper lobe, with some pleural thickening, probably multiple cavities, and no aspergilloma. The trachea is deviated to the left. Some bronchiectasis is also visible in the left lower lobe. (B) CT scan of the thorax in the same patient, showing multicavity disease on the left with a single fungal ball (arrow) in one of the cavities. Moderate pleural thickening is visible around the cavities. (C) CT scan of the thorax in the same patient at a lower level of the thorax, showing a different configuration of cavities (which probably communicate with each other) with the same fungal ball, but larger in this cross-section. Also visible is a large bulla (air space) (arrow A) proximal to the abnormal lung adjacent (arrow B). Much less pleural thickening is visible at this level laterally.
(A) Chest radiograph from a patient with CCPA, showing a single large cavity occupying most of the left upper lobe, with minor overlying pleural thickening and no aspergilloma. There are some pericavitary infiltrates and possibly one or two additional cavities inferior to the main large cavity. (B) Arteriogram of a left bronchial artery approached via a right common femoral approach. An arch aortogram showed some hypervascularity in the left upper lobe. The aorta was explored with a variety of catheters. There were four vessels with abnormal vascularity distally: two bronchial arteries, an intercostal artery, and a large medial branch of the internal mammary artery. The bronchial artery is shown. There is a large hypervascular supply to the mid-portion of the left lung. It was not possible to obtain a stable catheter position, and with the catheter at the orifice there was reflux of contrast into the aorta (just visible). Neither the conventional catheter nor a microcatheter could be advanced deeper into the vessel in order to obtain a satisfactory position for embolization, so this vessel was not embolized, although two others were.
Survival (censored) over 6 years for patients with an “aspergilloma” in sarcoidosis compared to survival after TB. Taken from Tomlinson and Sahn (1987) with permission.
Chronic aspergillosis syndromes
Criteria for the diagnosis of fungus ball of the sinus a